Justify It: Standing Frames & Wheelchairs

Evolutionary biologists — as well as parents of infants nearing their first birthdays — know that a trait that distinguishes humans from most animals is our bipedal, upright position. But it doesn’t take a science degree to know that standing is deeply significant to human beings. We stand when our national anthem plays, and when a bride walks down the aisle. We take a stand for what we believe in, and stand with friends in difficult times.

When illness or injury makes it impossible for us to stand spontaneously, the yearning remains. Fortunately, assistive technology advances make it possible for many wheelchair users today to stand.

Then what’s standing in the way? Some payors that, for reasons ranging from lack of belief in its efficacy to those seemingly just out to save money, say no.

Humans Are Made to Stand

Standing is so deeply rooted in us that even people outside the industry are talking about it. Do an Internet search for “office sitting danger,” and you’ll find a slew of stories with such headlines as “Dangers of Being Glued to Your Chair” (U.S. News & World Report, October 2012), “The Most Dangerous Thing You’ll Do All Day” (Men’s Health, March 2011) and “7 Ways Sitting Will Kill You” (Popular Science, February 2013).

Mainstream wisdom finally seems to be catching up with what seating & mobility clinicians have known for decades.

“Immobility is extremely hard on the body,” says Amy Morgan, PT, ATP, national clinical education manager at Permobil. “And it doesn’t take long to see the negative impact made by a lack of standing. We see this in new research looking at healthy adults who sit most of the day: Despite a regular workout routine, they have negative health issues associated with prolonged sitting.”

A newly updated position paper by the Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) underlines the benefits of standing (see sidebars). Many potential gains can also directly lead to a client’s greater success in performing mobility-related activities of daily living (MRADLs): feeding, toileting, grooming, dressing and bathing. Improved range of motion or reducing the risk of contractures, for instance — two potential benefits listed by RESNA authors — can make it possible for a wheelchair user to reach for his medication, or to reach for a pot in the kitchen to cook dinner.

Other signs that humans are supposed to stand, says Stephanie Tanguay, OTR, ATP, clinical education specialist at Motion Concepts, are the environments that we create for ourselves.

“For students, if you think about being at physics lab in high school, you have high stools and you’re up higher,” she points out. “I could not have done any of my dissecting in gross anatomy in college if I’d had to be in a wheelchair; none of the dissecting tables were accessible. Think of how many counters there are in businesses: How do you have any of those jobs if you’re sitting down? If I’m in a wheelchair that doesn’t go any higher than my seat-to-floor height — which is 20", say 22" on top of a cushion — and I’ve got a four-drawer file cabinet, I can only get into the two lower drawers.”

And at home: “Getting into a freezer or getting a glass out of the cupboard, those are usually above the regular counter in a kitchen. My bathroom mirror is above the sink, so I probably can’t see it. Try sitting down to brush your teeth sometime: Take a chair into the bathroom and try to lean over the sink. It’s tough.”

Medicare’s Stand on Funding

Today, stationary standing frames and positioning features in manual and power wheelchairs can enable people to stand even if they cannot independently do so. Different equipment models can achieve the standing position in different ways — e.g., prone, supine, sit-to-stand — according to what works best for the client.

Given the wealth of research on standing benefits, you might think funding sources would be eager to pay for technology that could reduce the need for more expensive medical interventions or institutionalized placements for wheelchair users.

But as with so many other funding issues, this one is not so straightforward. Let’s start with Medicare.

Nancy Perlich, COTA, ATP, reimbursement specialist for Altimate Medical, says, “Whatever is happening to CRT [complex rehab technology], that belt-tightening is happening to standing devices also. Unfortunately, we still see Medicare as not covering standing devices at all, of any sort.”

Morgan points out that Medicare’s Local Coverage Determination policy “has not changed and still regards standing wheelchairs as non-covered because they are ‘not primarily medical in nature.’”

That’s despite the fact that many potential benefits of standing, such as improvements in digestion and bowel/bladder function, “cross every diagnosis,” says Lauren Rosen, PT, MPT, MSMS, ATP/SMS, program coordinator at the Motion Analysis Center, St. Joseph’s Children’s Hospital of Tampa.

Rosen also points out that for wheelchair users, aging means more cumulative time spent in their chairs.

“There’s been research done about pressure sores and that people who stand have less pressure sores, which affects any full-time wheelchair user,” Rosen says. “Everybody’s susceptible to that, certainly more and more as you age. The more that you’re in a chair, the higher your risks.

“Post-menopausal women have more risk of being osteoporotic than a small child does. Anybody who’s not standing does, but certainly once you get to post-menopausal women, then you’ve got another issue thrown on top of not standing.”

But Rosen acknowledges, “Medicare doesn’t cover it. It’s still mind boggling as to why they won’t see the importance of it. Even though we have got multiple studies that show the benefit of it, they’re still not there yet.”

Medicaid & Private Payor Policies

That’s unfortunately true for some other payors as well. With multiple private insurance payors plus 56 Medicaid programs in play, keeping track of all the different standing technology policies is challenging.

“We’ve had some really positive outcomes with Medicaids that did not cover standing devices in the past,” Perlich says. “There has been a change specifically in Ohio; it was actually an NCART attorney that did an appeal. Hopefully, we’re starting to see some of that change now, and that was six to eight months ago.”

The issue, Perlich says, is that the Medicaid program “said they’d only cover one type of standing device, and they can’t just pick and choose what they’re going to cover.” That resulted in the Medicaid director sending out a letter, Perlich says, “so we’re starting to see the changes in that. Medicaids generally will cover standing devices. And it’s generally always covered with the 0-21 [year-old] population, although it’s also covered for adults. It just might take more work.”

“In regard to Medicaid and private payors, we are having great success in getting standing devices funded,” Morgan says. “However, there are still many funding sources that attempt to exclusively use Medicare standards or even refer to standing as ‘experimental or investigational’ treatment. These erroneous types of denials are often overturned when a beneficiary follows through with their appeal rights.”

“There are two big private payors that have said in the past that with standing devices, there’s not enough research to prove efficacy,” Perlich says. “And what we’re seeing now is that policy is trying to trickle down in some of the Medicaid programs who have coverage through these payors.

“That’s not okay. Medicaid coverage policies are set by Medicaid, not by HMO or PPO or providers. So they cannot implement their coverage policies, meaning the private payors cannot implement their coverage policies for Medicaid.”

When Standing Claims Are Rejected

While funding sources can reject standing frame and wheelchair claims for many reasons — including the contention that research has not proven the effectiveness of standing technology — Morgan isolated some of the most common reasons for denials:

The equipment is not medically necessary, or is a comfort or convenience item.

Standing is an experimental or investigational technology.

Standing wheelchairs are a convenience; client can instead use a standing frame in addition to the primary (non-standing) wheelchair.

Group 4 power base, required for some standing systems, is denied.

When the standing technology is deemed not medically necessary by the payor, Morgan says, “The team needs to justify the specific medical/health outcomes for the client, as well as how their specific MRADLs are impacted by the standing feature.”

When Tanguay worked as a clinician and a CRT provider, she liked to combine medical benefits with functional benefits to make her justification more airtight.

For instance, Tanguay says, if she simply mentioned that a standing wheelchair would enable her client with spinal cord injury to stand at his kitchen counter to prepare meals, “The thing is if they have limited hand function, how much cooking are they really going to do for themselves? There can always be the naysayers in those types of things. So I think it’s great to look at justification that combines what it might enable somebody to do, as well as the physiological benefits of it — internally, what it’s going to do for them.”

So, Tanguay might tell the funding source that with a standing chair, her client could “get his Eggo waffles out of the freezer, get them into the toaster that’s on the unmodified kitchen counter, get a plate out of the cupboard that is above the kitchen counter, and can cook his own eggs on the stovetop. I want to talk about the physical things that somebody can do, and I want to reference the physiological benefits.” That would include “maintaining the integrity of the long bones [by] weight bearing on his femurs and his tibias and fibulas.”

Using Research to the Best Benefit

Fortunately, there’s plenty of research to show that standing is beneficial — one of the most recent pieces being RESNA’s updated position paper. But our experts agreed that simply attaching the RESNA paper or any other research piece to a claim isn’t enough.

When creating documentation for a standing wheelchair, Rosen says, “I do a quick Letter of Medical Necessity at the beginning of it, and then I do the eval. My Letter of Medical Necessity template includes putting in why they need each of those features — one of which would be standing. I say, ‘Mrs. Smith’s need for power standing is also consistent with the RESNA position on standing.’”

Even general research, Rosen says, needs to be specifically tied back to the individual client’s needs.

“You can’t just say there’s a research article about this, that standing is good, and not say why standing is good for Mrs. Smith,” she explains. “I go through and say, ‘She’s got constipation, she’s got spasticity, she’s got a history of pressure sores.”

Tanguay suggests helping the funding source connect the dots between research and the particular client on the claim. “If I’m going to talk about the benefits of standing for somebody who has a spinal cord injury, I want to reference research that has shown the benefit of standing with SCI patients,” she says. “I don’t want to reference the benefit of standing for consumers who have cerebral palsy. I want it to be apples to apples comparatively. I think that’s very important.”

The NCART Standing Device Funding Guide, developed last year by the organization’s Standing Device Workgroup, can help providers and clinicians to stay on track when creating their standing claims.

“We wrote this because we noticed that documentation for standing devices was lacking,” says Perlich, a member of that Workgroup. “So the whole group, which includes two legal advocates, helped to design it. The whole purpose of it was to guide clinicians, suppliers and consumers on the evaluation and product selection process, as well as medical necessity documentation.

“Areas that we found lacking [in denied claims] initially were really basic, like height and weight of the consumer. They might put in height, or they might put in date and age, but not really drawing that complete picture of the client. We were finding there was not always a complete functional and physical assessment written down. It doesn’t need to be three paragraphs long; it can be a paragraph explaining where they were in range of motion, strength, sensation, ADLs, etc.”

Perlich also says denied claims oft en lacked explanation of other types of equipment that the team considered. “Everybody wants to put down the trials, which is great, but they don’t talk about the process they went through to come to this conclusion and why those other devices were ineffective. They don’t necessarily have to have trialed them, but they need to think about that process that they go through in their heads, because that addresses least-costly alternative.”

For instance, if the team knew a supine and a prone stander wouldn’t work, Perlich says the claim should include that: “We ruled them out because of transfer height, they didn’t have enough support and alignment options, whatever the case may be for that client.”

Explain Why a Standing Regimen Will Work

In your documentation, don’t forget to include the details that explain why standing technology is a good fit for a particular client.

That includes, for instance, explaining why a Group 4 power base — which is the type of base required for some standers — is appropriate.

As an example, Morgan says, “The Group 4 base provides a more stable and solid base for the standing feature. Safety is the main reason a client may need the Group 4 base over a Group 3 base. The Group 4 chairs have more strict requirements regarding stability and range, which are beneficial when using a standing feature. An adult standing feature on a Group 3 base raises a concern for safety due to less stability in the base to support that client in standing.”

Perlich suggests noting that the device’s physical dimensions will fit into the environments in which it will be used. That includes the home, plus other locations such as school and work, as applicable.

She also recommends including information on how the device will be used — for example, stating that the client is able to use the device independently, or that the client needs assistance and that caregivers are available to help.

“We weren’t always seeing evidence that the consumer could use the device independently or with appropriate assistance,” Perlich says, referencing what the NCART Standing Device Workgroup discovered during their research on documentation. “[The team] didn’t write it down.”

How about a payor who wants a client to use a standing frame when the seating & mobility team has determined that a standing wheelchair would be the better fit?

“I heard of a patient in the past couple of years who was trying to get funding for a power chair with power stand,” Tanguay says. “It was a consumer who had a standing frame and had caregivers at home, but it was a real struggle for them to transfer this particular patient into the standing frame. If you have somebody with very high tone and it takes two-plus people to transfer him in and you only have one caregiver at home, how often will he actually get in the standing frame?

If you really want the benefits of this, you need to stand every day. If I have to have two people to help me get in and out of my equipment, doesn’t it make more sense to have a standing chair? Once I’m in the chair, I can stand straight.”

Rosen suggests also tallying how the minutes can add up when a client is in a standing wheelchair.

“The benefit of having [standing ability] in a wheelchair is that you don’t need to do two hours of standing at a time,” she notes. “You need a cumulative two hours in your day. So what’s nice about the wheelchair stander is I can do it intermittently throughout the day.”

Time spent standing while performing ADLs, for instance — standing to brush teeth, use a mirror, etc. — counts toward that daily standing goal. “I can get 20 to 30 minutes of standing right there,” Rosen says. “And then I sit down and go to my job.”

Thinking Outside the Usual Funding Box

While standing technology and accompanying research is not new — its existed in the form of tilt tables and weight-bearing information since the 1950s, Perlich says — an increasingly challenging funding climate is forcing clinicians and ATPs to become more thorough and innovative in employing funding strategies.

Tanguay says, “In a day and age when we are seeing more questioning of the appropriateness of standing equipment from private insurance and from worker’s comp, what used to be considered a slam dunk isn’t a slam dunk anymore.”

In response, she says, more creative thinking might be required.

“We used to get some consideration from rehab services or jobs commissions, where they might pay for a portion. And sometimes I think that’s what we really have to do, to be more creative now. You might get the chair paid for by one funding source, and then have to look at an alternative source for aspects of it. Maybe the standing feature can get paid for privately, or the standing feature might get paid for by a jobs commission vs. out of pocket.”

Another documentation challenge stems from how difficult it is to immediately show the benefits of standing by using photos or videos — a common ATP and clinician tactic when seating is involved.

“It’s always nice to, if you’re going to try to get lateral tilt funded, to get pictures of the lateral tilt to show the benefit,” Tanguay says as an example. But benefits of standing can’t be instantly captured with a digital snapshot. “The only way you’re going to know that is to use it with regularity, every day for x amount of time,” she says. “There are all kinds of physiological benefits to it, but it’s not necessarily something that you can say, ‘He stood for 30 minutes in therapy, three times for two weeks and he’s so much better.’”

Tanguay suggests that if the client has the resources, joining a gym with standing equipment could enable the team to gather information to use as justification: “It’s a way that you might have a track record. If somebody has access, if there’s a facility where they can do that, you can log it like you would record what they’re lifting or how long they’re on a bike.”

After a few months at the gym, the client could, for instance, report on any decreases in bladder or urinary tract infections. “It’s not a quick solution,” Tanguay says. “It’s hard to gather data that can be used, like individual patient documentation and justification.”

As for that tricky question of the social and emotional benefits of standing: Rosen says she includes them in documentation “because I think those are important. Do funding sources think that they’re important? No, in most cases. But to me it’s one of the important reasons we’re [asking for funding], so the child or the adult can be face to face with the people to whom they’re speaking. So the kid can write on the dry-erase board. That’s important stuff for self-esteem. And I do feel that it’s important enough that I list it in my documentation for kids and adults.”

And Rosen says she prepares her clients and families for a denial early in the process.

“I tell my families to go in assuming that we’re going to get a denial the first shot,” she says. “And if I do have to do a second submission, you can bet that’s going in with a lot more research.

“I warn them this is not something that’s always the easiest thing to get funded, and not a lot of people ask for it, so a lot of insurance companies deny it the first shot. But we always get an appeal, so when you get that documentation, don’t worry. We planned for this.”

This article originally appeared in the June 2014 issue of Mobility Management.